Clinical Outcomes of Multilevel Anterior Corpectomy and Fusion As a Revision Surgery of the Cervical Spine: Report of Seven Cases

Case Report

Clinical outcomes of multilevel anterior corpectomy and fusion as a revision surgery of the cervical spine: report of seven cases

K Fushimi1, K Miyamoto1,*, H Nishimoto2, H Hosoe1, H Kodama1 and K Shimizu1 1Department of Orthopaedic Surgery, Gifu University School of Medicine, 1-1 Yanagido, Gifu, Japan; 2Department of Orthopaedic Surgery, Gifu Central Hospital, 3-25 Kawabe, Gifu, Japan

Study Design: Report of seven cases. Objective: There is no general consensus on the best surgical procedures for late-onset complications of cervical operations. We reported seven patients who had been treated effectively by multilevel anterior corpectomy and fusion (ACF) as revision surgery of the cervical spine. Setting: Gifu University Hospital, Gifu, Japan. Method: Multilevel ACF using autogenous fibular strut graft as revision surgery was performed on seven patients: four patients havingdisorders of adjacent discs after anterior discectomy and fusion and three patients havingpostlaminoplasty disorders. Japanese Orthopedic Association scores (JOA scores) of the cervical myelopathy and severity of radicular and axial pains were used to evaluate outcomes. Results: Rigid osseous fusion was achieved in all patients. JOA scores of the cervical myelopathy and the radicular pain, which had worsened just before the revision surgery, were improved significantly. Conclusion: In the present seven patients who had variety of pathological conditions with various previous surgeries, multilevel ACF using strut graft was effective as a revision procedure in amelioratingtheir symptoms. Spinal Cord (2006) 44, 449–456. doi:10.1038/sj.sc.3101868; published online 29 November 2005

Keywords: revision surgery; corpectomy; fusion; cervical spine

Introduction Developments of various surgical procedures, such as anterior corpectomy and fusion (ACF)9,17,18 have anterior1–3 and posterior decompression surgery4–6 for been performed in accordance with the pathological cervical spondylotic myelopathy and ossification of the conditions. Here, we report efficacies and pitfalls of posterior longitudinal ligament (OPLL) have provided multilevel ACF usinga fibular strut graftas revision patients with satisfactory outcomes.1–6 Several long-term cervical surgery. Although this study reviews only a follow-ups of these operations, however, have indicated small number of patients as a preliminary study, it is late-onset complications, includingdegeneration of suggested that multilevel ACF using strut graft is one of adjacent discs and pseudoarthrosis after cervical the effective solutions for a variety of symptoms fusion,7–9 and recurrence of spinal canal stenosis after followingfailed cervical surgery. expansive laminoplasty.6,10,11 Complications in such cases often involve a combina- Materials and methods tion of factors, such as instability, compression of the spinal cord and nerve roots by spurs, herniated discs, Materials ossified masses, and malalignment of the cervical Seven patients, six men and one woman, with a mean spine.6,10–12 As revision procedures for these complica- age of 53.6 years, participated in this study (Table 1). tions, posterior approaches such as interspinous They had all undergone surgical treatment for cervical wiring,13,14 foraminotomy,15 and posterior fusion,16 or myelopathy, but the outcomes were unsatisfactory. Four patients who had undergone anterior discectomy *Correspondence: K Miyamoto, Department of Orthopaedic Surgery, and fusion exhibited new disorders at adjacent Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu discs (patients 1–4) (Figure 1a and b) and three patients 501-1194, Japan who had undergone laminoplasty exhibited a pnlCord Spinal 450 utlvlcria opcoya eiinsurgery revision a as corpectomy cervical Multilevel

Table 1 Summary of seven patients who underwent subtotal corpectomy as revision surgery

First operation Second operation (revision surgery)

Duration between ﬁrst Postop. follow- Diagnosis at the second operation, Corpectomy and second op. up period Patient no. Age Sex Initial diagnosis Method of operation or reason for failure levels (years) (years) a b

1 58 M Disc herniation AF (C5–6), PW (C5–6) Disorder of adjacent discs (C4–5, C6–7) C5,6 2.2 5.8 Fushimi K radiculo/myelopathy 2 68 M Disc herniation aAF (C3–4,C5–6–7) Disorder of adjacent discs (C4–5, C5,6,7 13.0 4.3 C7–T1) myelopathy tal et 3 54 F Disc herniation aAF (C5–6) Disorder of adjacent discs (C4–5, C6–7) C4,5,6 5.0 2.2 radiculo/myelopathy 4 35 M Disc herniation aAF (C5–6) Disorder of adjacent discs (C3–4, 4–5, C4,5,6 9.7 1.9 6–7) myelopathy 5 52 M Spondylotic Laminoplasty (C3–7) Intraforaminal spur (C4–5,C5–6) slip C4,5 2.1 3.1 myelopathy, disc (C3–4, 4–5, 5–6), radiculo/myelopathy herniation 6 52 M Spondylotic Laminoplasty (C5–7) Spondylotic change, disc herniation C4,5,6 4.5 2.8 myelopathy (C3–4), slip (C3–4, 6–7), radiculo/ myelopathy 7 56 M OPLL Laminoplasty (C3–7) Insuﬃcient recovery after ﬁrst surgery C3,4 2.2 1.5 laminectomy(C1–2) myelopathy

ave.7SD 5.574.3 3.171.5 aAF ¼ anterior fusion bPW ¼ posterior wiring Multilevel cervical corpectomy as a revision surgery K Fushimi et al 451

Figure 2 (a, b) Representative ﬁndings of patient 5. Pain and paresthesia remained in the left arm of a 52-year-old man who had undergone laminoplasty from C3 to C7 for cervical spondylotic myelopathy. (a) CT-myelogram demonstrated disc bulging and spur formation in the left neural foramen (black arrow) at the C5–6 level. (b) CT scan after two-level corpectomy shows successful anterior decompression

Two- or three-level ACF usingautogenous fibular strut graft was performed in all the patients as revision surgery. The indications of this procedure was strictly limited to multilevel anterior lesions or evidence of multilevel intervertebral instabilities of the cervical Figure 1 (a, b) Representative findings of patient 3. Pain spine, as demonstrated by physical examinations, recurred in the left upper extremity of this 54-year-old woman dynamic X-rays, MRI, and myelo-CT studies. The after C5–6 anterior discectomy and fusion. (a) Sagittal MR mean interval between the first and revision operations image demonstrating disc protrusions at the adjacent discs was 5.5 years. The patients were followed up after the (C4–5, C6–7) (white arrows). (b) Lateral radiograph of the revision operation for 3.1 years on average. cervical spine 3 months after the corpectomy of C4, 5, and 6 and anterior fusion from C3 to C7 Surgical procedures worsened neurological status (patients 5–7) (Figures 2, A subtotal anterior corpectomy, with microscopic 3a and b). There were a variety of reasons for the removal of the discs and all vertebral body but the postlaminoplasty disorders (Table 1). All patients lateral walls of the vertebra, was performed in all had cervical myelopathy or radiculomyelopathy due to patients. The posterior longitudinal ligament was cut spinal cord compression. open in the median line. Then, autogenous fibula strut

Spinal Cord Multilevel cervical corpectomy as a revision surgery K Fushimi et al 452

employed in two patients (patients 5 and 7) who were immobilized with a hard collar until osseous fusion was confirmed. The five patients were immobilized for 3 months with halo vests, after which they worn hard collars until osseous fusion was confirmed.

Evaluation of clinical outcomes Radiographic evaluations Osseous fusion: The state of the osseous fusion was evaluated from plain X-ray films and CT. Trabecular continuity between adjacent vertebra and the fibular strut graft and, on lateral X-ray films, stability during flexion and extension of the cervical spine were evaluated. The time taken to achieve osseous fusion after the second surgery was also noted.

Symptoms Neurological status: The neurological status was evaluated accordingto the Japanese Orthopedic Association (JOA) scoringsystem 19 (Table 2), in which the maxi- mum score is 17. Patients were evaluated just before the first surgery, 6 months after the first surgery, just before the second surgery, and at the final follow-up.

Other symptoms: The presence of radicular pain and axial pain was evaluated. The axial pain included posterior neck pain, neck stiffness, and shoulder stiffness.20,21 We paid particular attention to these pains because the JOA scoringsystem does not evaluate the pain (Table 2). The severity of pain was graded accordingto the classification by Robinson et al,1 with modification.14 The pain was classified as mild if there was no limitation of activities, moderate if there was minimal limitation of activities with occasional use of anti-inflammatory medications, and severe if there was apparent limitation of activities with frequent use of anti-inflammatory medications for the relief of pain.14

Complications Intraoperative and postoperative complications were evaluated.

Results Figure 3 (a, b) Representative findings of patient 7. A 56- year-old man had undergone C3–7 laminoplasty for OPLL. Radiographic evaluations However, the neurological recovery was insufficient. (a) Osseous fusion Rigid osseous fusion was achieved in Sagittal MR image demonstrating C2–5 OPLL. After the seven patients 7.3 months on average (range, 5–9 laminoplasty, decompression for the spinal cord was insuffi- months) after the second surgery. cient (white arrows). (b) MR image after the corpectomy of C3 and 4, and anterior fusion from C2 to C5. Ossified masses were removed and spinal cord shifted anteriorly Symptoms Neurological status The average JOA score was graft was swedged into end plate. Four patients (patients 11.173.3 (average7SD) before the first surgery, 2, 3, 4 and 6) had three-level ACF employingfibula strut 13.073.4 6 months after the first surgery, 10.674.8 just autograft, while three (patients 1, 5 and 7) had two-level before the second surgery and 13.672.9 at the final ACF. An anterior cervical plate (PEAK anterior follow-up. In six patients, the JOA score was improved cervical plate, Depuy-AcroMed, MA, USA) was by 2–4 points after the second surgery. In one patient

Spinal Cord Multilevel cervical corpectomy as a revision surgery K Fushimi et al 453

(patient 1), the JOA score was unchanged after the second surgery, but radicular pain in the upper extremities, which was his preoperative chief complaint was improved signiﬁcantly. The JOA score did not fall in any of the patients (Table 3).

Axial pain Just before the second surgery, three patients complained of axial pain, includingneck pain and shoulder stiffness. In one patient (patient 1), the axial pain was persistent even before the first surgery. In two patients (patients 4 and 6), who had undergone posterior procedures, axial pain onset several months after the first surgery. After the second surgery, the axial pain remained unchanged in one patient and improved somewhat in two patients. There were no new occur- rences of axial pain.

1. Mild sensory loss 1. Severe disturbance 1. Mild sensory loss2. Normal 0. (Pollakisuria, Severe urine sensory hesitancy) loss 2. Normal Radicular pain Before the second surgery, all the

A. Upper Extremity 0. Complete disturbance B. Lower extremity patients had radicular pain in the upper extremities or trunk. After the second surgery, the radicular pain disappeared in four patients and improved in three.

Complications There were no intraoperative complications. Postopera- tively, we observed transient pain at the ﬁbular donor site in two patients (patient 2 and 4). These complaints had continued for 2–3 months, but they disappeared in both patients after 6 months. Gait problems due to donor site pain were not observed.

Discussion In this study, the JOA scores and the levels of radicular pain, which had worsened just before the second surgery, were improved significantly without neurological complications, after the multilevel ACF procedures. Rigid osseous fusion was successfully obtained in five patients without plates and in two patients with anterior plates. These results suggested that two- or three-level ACF usinga strut graftwas effective solution for these symptoms followingfailed cervical surgery. After havingundergoneanterior discectomy and fusion, four patients in the present series (patients 1–4) had adjacent disc disorders, a common long-term complication.7,8,22 We performed multilevel ACF with strut graft on them, because their adjacent disc disorder involved more than two disc levels. Several surgeons have reported that strut grafting provides structural stability and multilevel arthrodesis has a high union rate.22,23 Bohlman et al2 performed discectomy and interbody grafting on patients with adjacent disc disorders, but the success rate of fusion was less with multilevel procedures than with single level procedures. For the same pathological condition, Hilibrand et al22 Criteria of evaluation of cervical myelopathy by the Japanese orthopaedic association (JOA) score demonstrated that strut grafting resulted in a higher rate (100%) of arthrodesis than did multilevel interbody grafting (63%). In the present study, by using fibular

Table 2 I. Upper extremity function0. Impossible to feed oneself1. Possible to eat with spoon, but not with chopsticks2. Possible to handle chopsticks, 1. but Need inadequately cane or aid on3. ﬂat Possible ﬂoor to handle chopsticks, but awkwardly4. 2. II. Normal Need Lower cane extremity or function aid only on stairs 0. Impossible to walk 3. Possible to walk without cane or aid, but slowstrut 2. Normal C. Trunk grafting, 0. Severe sensory III. Sensory loss 2. Mild disturbance (Straining, rigid dribbling of urine) 3. Normal osseous 0. Severe sensory IV. loss Bladder function 4. Normal fusion was successfully 1. Mild sensory loss

Spinal Cord Multilevel cervical corpectomy as a revision surgery K Fushimi et al 454

obtained in all four patients with adjacent disc disorders. In addition, autogenous grafting may be responsible for 24 1.3 the 100% fusion rate observed in our patients. In two 8 8 7 patients in this series (patients 3 and 4) normal cervical 7.3

fusion after lordosis was not maintained. Therefore posterior

Period of rigid decompressive surgeries such as laminoplasty should surgery (months) not be reserved for these patients without well-preserved cervical lordotic curvature.25 Three patients (patient 5–7) had postlaminoplasty disorders includingsecondary slip, spur formation, disc herniation, and insuﬃcient decompression. These at ﬁbular donor site Symptoms (transient) (transient) late-onset disorders followinglaminoplasty have been discussed only a little.6,10,11 In a 5-year follow of 33 patients who underwent expansive laminoplasty, Satomi et al6 observed the recurrence of spinal canal stenosis Final

follow-up and neurological deterioration in six (18%) of them. In the present series, there was a variety of reasons for the postlaminoplasty disorders. In patient 5, radicular pain did not improve satisfactorily after the laminoplasty because of nerve root impingement at the neural foramens (Figure 2a). Baba et al15 showed that decompression of intraforaminal lesions by lamino- second surgery Just before the plasty is tends to be unsatisfactory. In patient 6, worsening of spondylotic change and disc bulging caused spinal canal stenosis at C3–4 which had not been decompressed duringthe laminoplasty. In a 0.05) Final literature search, we found only two reports of adjacent 11,26 follow-up o disc degeneration occurring after laminoplasty. P Wang et al11 suggested that it occurs because of 0.05) stiﬀeningof the operated segments. In addition, in o

P patients 5 and 6, who had spondylotic myelopathy, we observed worseningof degenerative slip (patient 5: surgery the second Just before C3–4, C4–5, C5–6, patient 6: C3–4, C6–7). Kimura et al10 reported that degenerative slips were worsened in four (14%) of 29 patients who underwent laminoplasty 2.9

7 for spondylotic myelopathy during7.1 years of follow-

Final up. In these conditions, decompression of anterior follow-up elements and intervertebral stabilization were both necessary. In patient 7, who had undergone laminoplasty for OPLL, neurological recovery after the first 4.8 *13.6 surgery was insufficient. The insufficiency of the decom- 7 pression was clear from the insufficient posterior shifting surgery the second Just before of the spinal cord and was probably caused by massive anterior impingement by OPLL and malalignment of the cervical spine (Figure 3a and b). Sodeyama et al27

3.4 10.6 found that posterior shifts of the spinal cord of more 7 than 3 mm, which is closely implicated in neurological JOA score (points) Axial pain Radicular pain after the 6 months recovery after laminoplasty, could not be expected when ﬁrst surgery the cervical spine is malaligned. Axial pain is reported to occur frequently after posterior cervical surgery such as laminoplasty.20,28 This 3.3 13.0

7 is why we gave it particular attention in this study, despite it not beingincluded in the JOA scoringsystem. Before the

First surgery In the present study, axial pain was remained in two patients after posterior surgery and in one patient after

SD 11.1 anterior surgery. The ACF revision surgery did not Preoperative and postoperative clinical outcomes

7 resolve this symptom completely in these patients and presumably, the axial pain may be a symptom from surgical damage or disuse atrophy of the nuchal muscles 14,21 *Significant improvement, compared with the JOA score before the first surgery ( Table 3 Patient no. 123456 157 11Average 13 12*Significant 16 improvement, compared with the 14 JOA 5 score just 13 before the second 13 surgery ( 9 16and 16 11ischemia 7 15 13 10 13 16 of 14 the 13 5 14 Moderate shoulder 16 3 None Mild 16 None Moderate muscles. 9 None 10 Moderate Mild None Mild Moderate None None None Moderate Mild Mild None None None No None Moderate Yes None Severe Moderate No Mild Yes 9 Mild Mild No No 7 No 8 6 5

Spinal Cord Multilevel cervical corpectomy as a revision surgery K Fushimi et al 455

In contrast, several complications have occurred after 9 Tribus CB, Corteen DP, Zdeblick TA. The efficacy of ACF with strut grafting, for example, graft extrusion, anterior cervical platingin the managementof sympto- migration, and pseudoarthrosis.29,30 Some surgeons matic pseudoarthrosis of the cervical spine. Spine 1999; 24: have recently performed simultaneous posterior fusion, 860–864. which is useful for avoidinggraftextrusion. 31,32 10 Kimura I, Shingu H, Nasu Y. Long-term follow-up of cervical spondylotic myelopathy treated by canal- Although we observed no graft extrusion in our expansive laminoplasty. J Bone Joint Surg Br 1995; 77: patients, when there is severe malalignment of the 956–961. cervical spine, such as postlaminectomy kyphosis, 11 WangMY, Green BA, Vitarbo E, Levi AD. Adjacent 29 posterior fusion is necessary. segment disease: an uncommon complication after cervical To summarize, the ACF procedure, as a revision expansile laminoplasty: case report. Neurosurgery 2003; 53: surgery, provided satisfactory results in all seven 770–772; discussion 772–773. patients who had unfavorable results after previous 12 Albert TJ, Vacarro A. Postlaminectomy kyphosis. Spine cervical anterior fusion or laminoplasty. However, this 1998; 23: 2738–2745. procedure must be indicated after careful consideration 13 Siambanes D, Miz GS. Treatment of symptomatic anterior of the patients’ pathological condition. A long-term cervical nonunion usingthe RogersInterspinous wiring techniques. Am J Orthop 1998; 27: 792–796. follow-up is necessary to demonstrate the efficacy of this 14 Wada E, Suzuki S, Kanazawa A, Matsuoka T, Miyamoto procedure for cervical revision surgery. S, Yonenobu K. Subtotal corpectomy versus laminoplasty for multilevel cervical spondylotic myelopathy: a long-term follow-up study over 10 years. Spine 2001; 26: Conclusion 1443–1448. 15 Baba I, Chen Q, Uchida K, Imura S, Morikawa S, Multilevel ACF usinga fibular strut graftperformed as Tomita K. Laminoplasty with foraminotomy for coexisting revision surgeries in seven patients following failed cervical myelopathy and unilateral radiculopathy. A cervical surgery was successful, at least according to a preliminary report. Spine 1996; 21: 196–202. short- to mid-term follow-up. This report suggests that 16 Abumi K, Kaneda K, Shono Y, Fujiya M. One-stage multilevel ACF can be performed effectively as revision posterior decompression and reconstruction of the cervical spine by usingpedicle screw fixation systems. J Neurosurg surgeries in patients with adjacent disc disorders Spine 1999; 90: 19–26. occurringafter anterior fusion and with a variety of 17 Kim CW, Abrams R, Lee G, Hoyt D, Garfin SR. Use disorders occurringafter laminoplasty. of vascularized fibular grafts as a salvage procedure for previously failed spinal arthrodesis. Spine 2001; 26: 2171–2175. References 18 Zdeblick TA, Bohlman HH. Cervical kyphosis and treatment by anterior corpectomy and strut grafting. 1 Robinson RA, Walker AE, Ferlick DC, WieckingDK. The J Bone Joint Surg Am 1989; 71: 170–182. result of anterior interbody fusion of the cervical spine. 19 Japanese Orthopedic Association. Scoringsystem for J Bone Joint Surg Am 1962; 44: 1569–1587. cervical myelopathy. J Jpn Orthop Asso 1994; 68: 2 Bohlman HH, Emery SE, Goodfellow DB, Jones PK. 490–503, (in Japanese). Robinson anterior cervical discectomy and arthrodesis for 20 Hosono N, Yonenobu K, Ono K. Neck pain and shoulder cervical radiculopathy. Long-term follow-up of one hun- pain after laminoplasty: A noticeable complication. Spine dred and twenty-two patients. J Bone Joint Surg Am 1993; 1996; 21: 1969–1973. 75: 1298–1507. 21 Yoshida M et al. Does reconstruction of posterior 3 Riley Jr LH, Robinson RA, Johnson KA, Walker AE. The ligamentous complex with extensor muscle decrease axial result of anterior interbody fusion of the cervical spine. symptoms after cervical laminoplasty? Spine 2002; 27: Review of 93 consecutive cases. J Neurosurg 1969; 30: 1414–1418. 127–133. 22 Hilibrand AS, Yoo JU, Carlson GD, Bohlman HH. The 4 Hirabayashi K, Miyakawa J, Satomi K, Maruyama T, success of anterior cervical arthrodesis adjacent to a Wakano K. Operative result and potoperative progression previous fusion. Spine 1997; 22: 1574–1579. of ossification amongpatients with ossification of cervical 23 Nirala AP, Husain M, Vatsal DK. A retrospective study of posterior longitudinal ligament. Spine 1981; 6: 354–364. multiple interbody grafting and long segment strut grafting 5 Itoh T, Tsuji H. Technical improvements and results of followingmultilevel anterior cervical decompression. Br J laminoplasty for compressive myelopathy in the cervical Neurosurg 2004; 18: 227–232. spine. Spine 1985; 10: 729–736. 24 Malloy KM, Hilibrand AS. Autograft versus allograft in 6 Satomi K, Nishu Y, Kohno T, Hirabayashi K. Long-term degenerative cervical disease. Clin Orthop Relat Res 2002; follow-up studies of open-door expansive laminoplasty for 394: 27–38. cervical stenotic myelopathy. Spine 1994; 19: 507–510. 25 Sani S, Ratliff JK, Cooper PR. A clonical review of cervical 7 Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, laminoplasty. Neurosurg Q 2004; 14: 5–16. Bohlman HH. Radiculopathy and myelopathy at segments 26 Takagi H, Kawaguchi Y, Kanamori M, Abe Y, Kimura T. adjacent to the site of a previous anterior cervical Case reports: T1-2 disc herniation followingan en bloc arthrodesis. J Bone Joint Surg Am 1999; 81: 519–528. cervical laminoplasty. J Orthop Sci 2002; 7: 496–497. 8 Katsuura A, Hukuda S, Saruhashi Y, Mori K. Kyphotic 27 Sodeyama T, Goto S, Mochizuki M, Takahashi J, Moriya malalignment after anterior cervical fusion is one of the H. Effect of decompression enlargement laminoplasty factors promotingthe degenerativeprocess in adjacent for posterior shiftingof the spinal cord. Spine 1999; 24: intervertebral levels. Eur Spine J 2001; 10: 320–324. 1527–1531; discussion 1531–1532.

Spinal Cord Multilevel cervical corpectomy as a revision surgery K Fushimi et al 456

28 Ratliﬀ JK, Cooper PR. Cervical laminoplasty: a critical 31 Epstein NE. Posterior cervical fusion failure in three review. J Neurosurg 2003; 98: 230–238. morbidly obese patients followingcircumferential surgery. 29 Riew KD, Hilibrand AS, Palumbo MA, Bohlman HH. Surg Neurol 2003; 60: 205–210; discussion 210. Anterior cervical corpectomy in patients previously man- 32 Schultz Jr KD, McLaughlin MR, Haid Jr RW, Comey CH, aged with a laminectomy: short-term complications. J Bone Rodts Jr GE, Alexander J. Single-stage anterior- and Joint Surg Am 1999; 81: 950–957. posterior decompression and stabilization for complex 30 WangJC, Hart RA, Emery SE, Bohlman HH. Graft cervical spine disorders. J Neurosurg Spine 2000; 93: migration or displacement after multilevel cervical cor- 214–221. pectomy and strut grafting. Spine 2003; 28: 1016–1021; 33 Saunders RL, Pikus HJ, Ball P. Four-level cervical discussion 1021–1022. corpectomy. Spine 1998; 23: 2455–2461.

Spinal Cord